addressing the global health workforce crisis: challenges for france ...

THE HUMAN RESOURCES FOR HEALTH CRISIS
MAPPING POLICIES
ADDRESSING THE GLOBAL HEALTH
WORKFORCE CRISIS: CHALLENGES
FOR FRANCE, GERMANY, ITALY,
SPAIN AND THE UK
PUBLISHED BY ACTION FOR GLOBAL HEALTH IN JANUARY 2011

Action for Global Health is a network of
European health and development
organisations advocating for the European
Union and its Member States to play a
stronger role to improve health in
development countries. AfGH takes an
integrated approach to health and advocates
for the fulfilment of the right to health for all.
One billion people around the world do not
have access to any kind of health care and we
passionately believe that Europe can do more
to help change this. Europe is the world
leader in terms of overall foreign aid
spending, but it lags behind in the proportion
that goes to health.
Our member organisations are a mix of
development and health organisations,
including experts on HIV, TB or sexual and
reproductive health and rights, but together
our work is organised around a broad
approach to health. AfGH works to recognise
the interlinkages of global health issues and
targets with a focus on three specific needs:
getting more money for health, making health
care accessible to those that need it most
and strengthening health systems to make
them better equipped to cope with
challenges and respond to peoples’ needs.
Visit our website to learn more about our work and how
to engage in our advocacy and campaign actions.
www.actionforglobalhealth.eu
FRONT COVER IMAGE © TERESA S. RÁVINA / FPFE

© TUGELA RIDDLEY/IRIN
CONTENTS
Acknowledements
This report was produced by Action for
Global Health and written by Rebekah
Webb.
Action for Global Health would like to thank
the many people that contributed to this
report including government officials in
France, Germany, Italy, Spain and the UK,
national institutions governing health
personnel, NGOs and the health workers
who agreed to be interviewed.
A special thank to Amref Italy that allowed
AfGH Italy to use the preview outcomes of
their monitoring report “Personale sanitario
per tutti, e tutti per il personale sanitario!
Executive Summary 4
1. Introduction 5
2. European Union Commitments to
Human Resource for Health (HRH) 8
3. How do Member State development
policies address the HRH crisis in the
developing world 10
- France 11
- Germany 12
- Italy 13
- Spain 14
- The UK 15
4. Case Studies:
- Madagascar: acute shortages of health
workers in rural areas 18
- El Salvador: plenty of doctors, yet still
on the critical list 20
5. Going Beyond the Code: Next Steps 22
6. Are Member State domestic health
policies addressing the HRH crisis
- France 26
- Germany 28
- Italy 30
- Spain 32
- The UK 34
7. Recommendations 36
Bibliography 38
List of Acronyms 38
3

© LILIANA MARCOS / FPFE
EXECUTIVE SUMMARY
In 2006, the World Health Organisation (WHO)
estimated that 57 countries, 36 of them in
Africa, were facing a severe shortage of
adequately trained and supported health
personnel. The international, and in some cases
targeted, recruitment of health care workers
from countries that need them most is one of
the major driving forces behind this crisis.
On 21 May 2010, the 63rd World Health
Assembly took the long-awaited step of
adopting a new WHO Global Code of Practice
on the International Recruitment of Health
Personnel. Ministers of Health agreed to stop
recruiting health workers from developing
countries unless agreements are in place to
protect the health workforce, and to provide
technical and financial assistance to these
countries as they strengthen their health
systems. Even a complete implementation of
the WHO code, however, is unlikely to
completely stem ‘brain drain’ in the health
sector, nor provide and retain sufficient
numbers of trained staff, particularly if other
factors beyond the code are left unaddressed.
This report compares the foreign and domestic
policies regarding health workers in the five EU
countries home to the Action for Global Health
(AfGH) network, which have some of the
highest densities of doctors and nurses in the
world. It looks at the reasons for health
shortages in both source and destination
countries, exploring what needs to change or to
be put into practice in order to fulfil the
requirements of the WHO Code of Practice and
to strengthen health systems in the developing
world. Two countries on the list of countries
below the minimum density of health
professionals recommended by WHO, El
Salvador and Madagascar, are included to show
how a chronic lack of investment in the health
sector has resulted in both high unemployment
rates among newly qualified doctors, and the
poor paying for the health care of the rich.
AfGH calls for European Member States to take
immediate action to simultaneously tackle the
push and pull factors driving the international
migration of health personnel, starting with full
implementation of the WHO Global Code of
Practice and the EU Programme for Action on
the Critical Shortage of Health Workers. EU
Member States must fully fund health systems
strengthening, ensuring that 25 % of all health
ODA is allocated to national health workforce
strategies and to reaching the target of an
additional 3.5 million new health workers by
2015. The full set of recommendations is given
at the end of this report.
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© LYNN MAUNG/IRIN
01 INTRODUCTION
On 21 May 2010, the 63rd World Health Assembly (WHA)
took the long awaited step of adopting a new WHO Global
Code of Practice on the International Recruitment of Health
Personnel, six years after the idea was first proposed.
Ministers of Health agreed to stop recruiting health workers
from developing countries unless agreements are in place to
protect the health workforce, and to provide technical and
financial assistance to these countries as they strengthen
their health systems.
This Global Code of Practice is long overdue. Current
unregulated large-scale migration is having a devastating
impact on the health systems of source countries – many of
which are struggling to meet the health Millennium
Development Goals (MDGs). In 2006, WHO estimated that
57 countries, 36 of them in Africa, were facing a severe
shortage of adequately trained and supported health
personnel 1 . The international, and in some cases targeted,
recruitment of health care workers from countries that need
them most is one of the major driving forces behind this
crisis.
In what has been described as a global ‘tug of war’,
countries all over the world are seeking to solve their health
worker shortages by recruiting from overseas, while health
workers, increasingly women, are seeking to improve their
situation by means of migration.
Globally, an extra 4.3 million health workers are needed to
make essential health care accessible to all 2 . Whether
wealthy or poor, most countries in the world are facing
increasing demands on their health systems and yet offer
unattractive working conditions to health professionals.
As a result, British midwives travel to Australia, Zimbabwean
doctors transfer to South Africa, Senegalese nurses
relocate to France and German doctors migrate to
Switzerland. Even in the face of their own shortages in rural
and underserved areas, countries such as India and the
Philippines continue to send trained nurses abroad.
A tiger without teeth
The Code of Practice is the first major international
recognition of the truly global nature of the health worker
shortage and the role that unregulated migration is playing in
undermining the health MDGs. The Code sets out guiding
principles and voluntary international standards for the
ethical recruitment of health workers, to increase the
consistency of national policies and prevent unethical
practices. It discourages states from actively recruiting
health personnel from developing countries that face critical
shortages and encourages them to facilitate the “circular
migration of health personnel” to maximise skills and
knowledge sharing when health care professionals return to
their home nations after time abroad. Bilateral agreements
between source and destination countries are highlighted
as critical for better international coordination of migration.
The Code recognises two different but equal rights – those
of communities to the right to health and the rights of
individuals who seek employment. Prior to the Code of
Practice, there was no existing legal and comprehensive
instrument applicable to both sending and receiving
countries.
The Code of Practice promises to have a significant impact
on the deplorable shortage of health workers in low-income
countries. However, the voluntary nature of the Code leaves
it vulnerable to dilution or being ignored. To meet the health
MDGs, WHO members will need to respect its provisions
fully. While it is important to respect the right of health
workers to migrate, both developing and developed
countries need to prioritise health systems strengthening
and use the Code of Practice as a tool to train and retain
health workers where there is most need.
Even a complete implementation of the WHO Code,
however, is unlikely to completely stem brain drain in the
health sector, nor provide and retain sufficient numbers of
trained staff, particularly if other factors beyond the Code
are left unaddressed. These include the role of private
sector actors continuing to recruit from developing
countries and the substantial gender dynamics of the crisis,
given that 80 % of the global health workforce is female 3 .
1 World Health Report, Working Together for Health, WHO, 2006.
2 World Health Report, Working Together for Health, WHO, 2006.
3 Merchants of Labour, ILO, 2006 and Human Resources for Health: A Gender Analysis,
A.George, July 2007.
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© LYNN MAUNG/IRIN
01 INTRODUCTION
Key points from the WHO Code of Practice
International recruitment of health personnel should be conducted in accordance with the principles of
transparency, fairness and promotion of sustainability of health systems in developing countries (art3.5)
Member States should strive to create a sustainable health workforce and work towards establishing effective
planning, education and training, and retention strategies that will reduce their need to recruit migrant health
personnel (art3.6)
Effective gathering of national and international data, research and sharing of information on international
recruitment are needed to achieve the objectives of the Code (art3.7)
Member States should facilitate circular migration of health personnel, so that skills and knowledge can be
achieved to the benefit of both source and destination countries (art3.8)
Destination countries are encouraged to collaborate with source countries to sustain and promote health human
resource development and training (art5.1)
Member States should use this Code as a guide when entering into bilateral, regional or multilateral agreements,
to promote international cooperation and coordination on international recruitment (art5.2)
Member States should consider adopting measures to address the geographical maldistribution of health
workers and to support their retention in underserved areas (art5.7)
Source: European Public Health Alliance (EPHA), 2010.
What is the minimum number
of health workers required
There is no universal norm or standard for a minimum
density or coverage of human resources for health (HRH) in
any given country or region recommended by the WHO.
However, the 2006 World Health Report estimated that
countries with a density of fewer than 2.28 doctors, nurses
and midwives per 1,000 people generally fail to achieve a
targeted 80 % coverage for skilled birth attendance and
child immunization. There is a direct relationship between
the ratio of health workers to population and survival of
women during childbirth and children in early infancy. As the
number of health workers declines, survival declines
proportionately.
The map below illustrates the huge scale of the need in
developing countries. In Africa, the density is only 0.8 health
workers per 1,000 people, compared to 10 per 1,000 in
Europe.
Territory size shows the proportion of all physicians
(doctors) that work in that territory.
© Copyright SASI Group (University of Sheffield) and Mark Newman
(University of Michigan).
6

In 2009, the High Level Taskforce on Innovative International
Financing for Health Systems (HLTF) offered two estimates
of the number of health workers required to achieve the
health-related MDGs. One, developed by the WHO, found
that 3.5 million more health workers (including additional
managers and administrators) across 49 low-income
countries were required to accelerate progress towards –
and in many cases to achieve – the health-related MDGs,
while also expanding coverage for other diseases and
contributing to the hunger target in MDG 1. The other set of
calculations, by the World Bank and other institutions, found
that these 49 countries required 2.6-2.9 million additional
health workers – including managers, whose critical role is
too often overlooked.
At present, Europe trains 173,800 doctors a year, Africa
only 5,100. This in itself is a problem that needs to be
addressed. But the situation is exacerbated by the hiring of
health personnel from Africa and other developing nations to
address staffing shortages in EU Member States. EU
Member States can and must plug their own staff shortfalls
by addressing their own health policies, thereby putting an
end to the 'pull factor' in health worker migration from
developing countries. Equally, they must also act to address
the ‘push factors’ in crisis countries, without which health
workers will continue to seek better opportunities, whether
in the EU or elsewhere.
With the entry into force of the Lisbon Treaty, the eradication
of poverty is the main objective of EU development
cooperation and policies. This is more than a noble ambition,
as treaty provisions on development are binding and
enforceable and require a commitment to policy coherence.
This means that EU and Member State policies must
support – or at the very least not harm – national, local and
regional efforts to eradicate poverty in Southern partner
countries. The EU must therefore ensure that its policies and
practices on the recruitment and retention of health workers
do not undermine progress on the health MDGs.
As the world's largest aid donor and one of the main
recruiters of health workers from developing countries, the
EU and its Member States have a major responsibility to
ensure the Code is respected and not watered down.
European Member States can support this commitment
by allocating 0.1 % of GNI to development health
spending, 25 % of which should focus on ways of
improving working conditions, pay and training for
doctors, midwives and nurses in the developing world.
About this report
This report compares the foreign and domestic policies
regarding health workers in the five EU Member States
home to the Action for Global Health network, which have
some of the highest densities of doctors and nurses in the
world. It looks at the reasons for health shortages in both
source and destination countries, exploring what needs to
change or to be put into practice in order to fulfil the
requirements of the WHO Code of Practice and to
strengthen HRH in the developing world. Two countries on
the list of countries below the minimum density of health
professionals recommended by the WHO, El Salvador and
Madagascar, are included to show how a chronic lack of
investment in the health sector has resulted in both high
unemployment rates among newly qualified doctors and the
poor paying for the health care of the rich.
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02 EUROPEAN UNION COMMITMENTS TO
HUMAN RESOURCES FOR HEALTH (HRH)
“
There is a global market for health workers,
but it is a distorted market, shaped by global
inequity in health care provision and the
capacity to pay workers, rather than by health
needs and the burden of disease
EU Strategy for Action on the Crisis in Human Resources
for Health in Developing Countries, 2005
There has been a longstanding understanding in Europe
that the shortages of health-workers in developing countries
is a critical factor preventing the scaling up of service
provision necessary to allow improved health care and
improved health indicators. At an EU level this awareness
came to the fore in reaction to the epidemics of HIV/AIDS,
Malaria, and Tuberculosis. In 2005 the EU adopted a
Programme of Action to combat these poverty diseases
through external action including a separate section devoted
to addressing the human resource crisis for health
providers. It was by then clear that the lack of health workers
in developing countries had reached a critical point and was
a major obstacle to the scaling up of services required to
confront not just the major infectious diseases but of
achieving all three of the health-specific MDGs:
“The lack of trained health providers undermines efforts
to scale up the provision of prevention, treatment and
care services. The EU will support a set of innovative
responses to the human resource crisis. At regional
level, the EC will use its support for the AU and the New
Partnership for Africa’s Development (NEPAD) to help
ensure strong African leadership in the formulation and
coordination of a response to the human resource crisis.
The aim should be to increase incentives for health
workers to remain in or return to developing countries or
regions where the need is greatest rather than to create
barriers to migration.”
- Programme for Action on AIDS, TB and Malaria, 2005
”
By the end of 2005, the European Commission had
adopted a Communication outlining an EU Strategy for
Action on the Crisis in Human Resources for Health in
Developing Countries. The actions proposed in the EU
Strategy for Action were comprehensive and covered
actions at country, regional and global level. At country level,
it called for support and financing for national human
resource plans and the inclusion of HRH issues in Poverty
Reduction Strategies. At regional level, it called for greater
leadership from the African Union and the New Economic
Partnership for African Development (NEPAD), as well as an
Inter-Ministerial Conference on Human Resources for
Health in Africa. Globally, the concept of a European Code
of Conduct and circular migration were among the main
actions recommended.
Programme for Action to tackle the
shortage of health workers in
developing countries
In December 2006 the European Commission adopted a
Communication outlining a ‘Programme of Action’, broadly
following the previous Communication, but also adding
some important elements, such as more detailed actions to
specific world regions, as well as commitments towards
finance, and monitoring and evaluation. The Programme of
Action also went into greater detail than had previously been
the case on the links between EU health, employment, and
migration policies and the human resources for health crisis
in developing countries. This was reflected in the priorities
identified by the Council of Ministers in their Council
Conclusions on 14 May 2007 where they highlighted the
need for:
8

4 Policy Coherence for Development - Establishing the policy framework for a whole-ofthe-Union
approach COM (2009) 458 adopted 15 September 2009 was accompanied
by a staff working paper. Quote from page 1999.
(http://ec.europa.eu/development/icenter/repository/SWP_PDF_2009_1137_EN.pdf)
5 COM(2007) 630 European Commission White Paper ‘Together for Health: A Strategic
Approach for the EU 2008-2013’ was adopted on 23 October 2007.
6 Ministers meeting on 5-6 December 2007 in the Employment, Social Policy, Health and
Consumer Affairs Council of Ministers adopted conclusions
(http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/97445.pdf
) drafted on 29 November 2007 by the Health Permanent Representatives Committee.
(http://register.consilium.europa.eu/pdf/en/07/st15/st15611.en07.pdf).
7 COM(2008) 725 Green Paper on the European Workforce for Health adopted 10
December 2008.
• Developing principles for the recruitment of health
workers from developing countries to work in the EU;
• An EU code of conduct for the recruitment of health
workers;
• Improved information systems (especially statistics) on
human resources for health;
• Expanding medical education and health staff training and
supporting regulatory agencies in improving standards
and achieving a balance between demand and supply for
qualified staff;
• Exploring ways and means to facilitate the temporary
migration of health workers from developing countries into
the EU.
Evidence of any impact on the ground of these
commitments has been at best sparse. Indeed, the EU
Commission’s own report on Policy Coherence for
Development some two years after these Council
Conclusions found “little evidence that the EU through its
policies has contributed to reducing migration of health
workers from the three African countries to the EU so far” 4 .
EU Health Workforce Policies
There has been some recognition of the need for EU
Member States to change their domestic policies in line with
development policy.
In October 2007, the EU Commission adopted a White
Paper entitled ‘Together for Health: A Strategic Approach
for the EU 2008-2013’ 5 . This White Paper explicitly
included the adoption of the Programme of Action when
referring to the need to ensure the principle that “health in all
policies” was attained. The White Paper also highlighted the
need for the EU to take a leadership role in global health,
particularly so as to achieve the health related MDGs and
principles of Aid Effectiveness. Half the principles of the
White Paper related to global health in general and included
specific reference to the health workforce crisis.
The reaction to the White Paper by the Council of Ministers
endorsed the approach and included recognition of:
“the need to strengthen the health perspectives in EU
external policies, including global health and for
tackling issues related to the migration of health
professionals, development aid in the field of health,
trade in health products, and sharing EU health values
with other countries.”
And underlined:
“the need for effective implementation of the Strategy,
based on close and structured dialogue with the
Member States and civil society as well as on regular
monitoring of the progress achieved.” 6 .
Following the adoption of the EU Health Strategy a
consultation on issues relating to the EU Health Workforce
was opened with the adoption of a Green Paper. This Green
Paper included the problem of health sector ‘brain drain’ of
health workers migrating from developing countries to the
EU. The Green Paper was largely descriptive of the
preceding policy initiatives, but did highlight the need for
both the inclusion of measures to combat brain drain issues
in migration policies in general, and the need to elaborate a
code of conduct on the ethical recruitment of health
workers:
“The EU has made a commitment to develop a Code of
Conduct for the ethical recruitment of health workers
from non-EU countries and to take other steps to
minimise the negative and maximise the positive
impacts on developing countries resulting from the
immigration of health workers to the EU. The need to
deliver on these commitments is reiterated in the
Progress report on the implementation of the PfA
adopted in September 2008.” 7
The Kampala Declaration and
Agenda for Action
In response to growing international concern about the
impact of health migration on health service delivery in
developing countries, the first ever Global Forum on
Human Resources for Health was convened in
Kampala, Uganda in 2008.
The Kampala Declaration and related Agenda for Action
called for higher commitment by governments and
development partners to human resources for health,
providing an overarching global framework for priority
actions to close the health worker gap within a decade.
The Global Health Workforce Alliance is tasked with
monitoring progress towards implementing the Agenda
for Action. Hosted by the WHO, the Alliance is a
partnership of national governments, civil society,
international agencies, finance institutions, researchers,
educators and professional associations dedicated to
identifying, implementing and advocating for solutions.
A key focus is the development and implementation of
evidence- and needs-based country HRH plans in
Africa, South Asia and Latin America.
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03 HOW DO MEMBER STATE DEVELOPMENT POLICIES
ADDRESS THE HRH CRISIS IN THE DEVELOPING WORLD
The countries reviewed in this report have all
made strong, vocal commitments to addressing
the shortage of health workers in the
developing world in multiple fora. As EU
Member States they are all signatories to the
Programme for Action to tackle the shortage of
health workers in developing countries. All of
them are members of the International Health
Partnership and related initiatives (IHP+),
designed to strengthen national health plans.
All except Spain are members of the G8 and the
Development Ministries of Germany, France and
the UK are partners in the Global Health
Workforce Alliance. In addition, each has made
specific commitments to the importance of
addressing HRH in their official development
policies. However, as the following profiles
show, some countries are doing more than
others in terms of practical initiatives and solid
funding commitments to address health worker
shortfalls.
G8 Commitments
In their role as G8 countries, the UK, Germany, France
and Italy have all made successive commitments to
addressing the critical shortage of health workers in
developing countries since the Gleneagles summit in
2005.
In 2008 in Toyako, Japan, the G8 pledged to “work
towards increasing health workforce coverage towards
the WHO threshold of 2.3 health workers per 1000
people, initially in partnership with the African countries
where we are currently engaged and that are
experiencing a critical shortage of health workers”. They
also committed to supporting the development of
robust health workforce plans and establishing specific,
country-led milestones. USD 60 billion was pledged to
fight infectious disease and strengthen health systems
by 2012.
At the 2009 G8 summit in L’Aquila, Italy, the G8
renewed their commitment to an integrated approach to
health, the importance of supporting national health
systems with universal coverage, promoting the
principles of Primary Health Care through active
involvement of civil society and finally promoting a multisectoral
approach to health that takes into account the
social determinants of health: “It is essential to
strengthen health systems through health workforce
improvements”.
This year, the G8 Muskoka declaration highlighted task
shifting as a way to make better use of scarce health
workers.
10

FRANCE
In 2009, France surpassed Germany as the largest
European donor country. However in terms of commitment
to global health, France sits in the middle of the countries
reviewed in this report, with only 0.041 % of GNI going to
health ODA 8 .
France has taken a leading role in recent years in putting
health systems strengthening on the international agenda,
including during the EU presidency in 2008. Strengthening
health care systems, especially human resources for health,
is one of three core pillars of French foreign policy on health
as set out in the ‘2007-2012 Global Strategy for
Cooperation and Development in the Health Sector’. The
initial focus of French efforts in this area was to fund training
programmes in developing countries. However, the
evaluations of this training policy, including one conducted
at the request of the Ministry of Foreign Affairs in 2000
throughout sub-Saharan Francophone Africa, highlighted
the lack of consistency and overall plan of this policy. It also
revealed a very sharp slowdown in scholarship policies and
a decline in fellowship training due to the decrease of direct
technical assistance.
In 2009, France published its ‘Strategy for the
strengthening of human resources for health in developing
countries’. This document sets out France’s future
commitments regarding the strengthening of health workers
at the bilateral and multilateral levels, the latter of which
absorbs the majority share of French ODA to health (69 % in
2009).
In respect to strengthening HRH, France supports 20
countries, mostly from Sub-Saharan Africa, with about 30
projects either entirely dedicated to human resources for
health or including a HRH component. The main focus of
these projects is training staff, building and furnishing health
facilities and financing the production and implementation of
national plans for HRH development. Some projects focus
on the ‘retention’ of health workers, helping health staff to
remain in the areas where they work, by providing them with
housing, a motorbike or with computers, desks and medical
equipment. In addition, France launched a hospital twinning
programme, ‘ESTHER’, which links hospitals in France with
health facilities in Africa, in order to provide comprehensive
and quality care for people living with HIV/AIDS and related
diseases. Among other activities, ESTHER includes the
training of health professionals in 18 developing countries.
France has signed nine bilateral agreements on migration
flows with countries in Francophone Africa to date. Some of
the ratified agreements (i.e. Senegal, Benin and Congo)
address the issue of migration with a comprehensive
approach and a particular focus on health professionals and
support for HRH development 9 . In addition, France seconds
an expert to the WHO in Geneva to work as the Coordinator
of the Health Workforce Migration and Retention
Programme 10 . The French government has also ratified the
WHO Code of Practice.
8 Source: 2010 Reality Check, Action for Global Health 2010. Figures refer to 2008.
9 Innovations in Cooperation. A guidebook on bilateral agreements to address health
workers migration, I. Dhillon, M. Clarck, R. Kapp, May 2010, ed. by Realizing Rights &
Aspen Institute.
10 Muskoka Accountability Report, Annex 5, G8, 2010.
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03 HOW DO MEMBER STATE DEVELOPMENT POLICIES
ADDRESS THE HRH CRISIS IN THE DEVELOPING WORLD
GERMANY
Germany is one of the largest European donors to overseas
development, allocating just over USD 1 billion to global
health in 2008. However Germany has some way to go to
reach the 0.1 % of GNI target, ranking only just above Italy
with 0.03 % 11 .
On the positive side, health systems strengthening (HSS) is
a strategic priority in German development cooperation on
health, with emphasis on health sector reform and building
workforce capacity 12 . In particular, the health sector strategy
positions efforts to strengthen human resources for health
(HRH) as an integral part of Germany’s HSS strategy and
these aspects are integrated into the overall
macroeconomic and health sector framework along four
dimensions: policy, management, the labour market and
education. A discussion paper on the HRH crisis was
published in 2010 13 .
Germany’s Ministry for Economic Cooperation and
Development (BMZ) does not calculate the resources
provided specifically on HRH. It has been estimated that a
range of 25-50 % of funds provided for health systems
strengthening can be attributed to capacity building, which
amounts to between USD 15.6 and USD 31.25 million in
2009 14 .
Meanwhile, the German technical development agency, the
Deutsche Gesellschaft für technische Zusammenarbeit
(GTZ) supports partner countries in their formulation of
health-policy strategies and staff development plans. It
advises on adapting legal frameworks and works towards
increasing the management, administrative and planning
capacities of health workers and health personnel. Other
priorities of German HSS activities are the decentralization
of health services and the development of social security
instruments, and the improvement of health infrastructure.
German engagement for human resources for health is
integrated in its broader health programmes; HRH support
is implemented both through projects and sector budget
support. Both instruments are integrated into existing
coordination structures, such as sector-wide approaches
(SWAps), where Germany prioritises human resource
management and planning.
Germany is directly involved in health sector reform
processes in 16 countries (Bangladesh, Cambodia,
Cameroon, Indonesia, Kenya, Kyrgyzstan, Malawi, Nepal,
Pakistan, Rwanda, South Africa, Tajikistan, Tanzania,
Ukraine, Uzbekistan and Vietnam). In addition, there are two
regional programmes, one in the Caribbean (Dominican
Republic, Haiti and Cuba) and one in West Africa (Ivory
Coast Guinea, Sierra Leone and Liberia). Some country
programmes deal with HRH as a cross-cutting issue while
others are implementing special programme components.
These health worker programme components include preand
in-service training by universities and other training
institutions, the development of E-learning curricula and
information systems, development of quality assurance and
standards, the creation of monetary and non-monetary
incentives to place and retain health workers, sector
financing, private service provision and community based
services improve HRH especially in rural and remote areas.
In addition, reintegration support is offered to professionals
who have trained in Germany when they return to their home
country.
12
11 Source: 2010 Reality Check, Action for Global Health 2010. Figures refer to 2008.
12 Germany’s global health strategy is defined in its health sector strategy: Federal
Ministry for Economic Cooperation and Development 2009. Sector Strategy: German
Development Policy in the Health Sector. Available at:
http://www.bmz.de/en/publications/type_of_publication/strategies/konzept187.pdf
13 BMZ (2009): Ansätze und Instrumente der deutschen Entwicklungspolitik im Bereich
Fachkräftemangel im Gesundheitswesen. Diskussionspapier des Thementeams
Gesundheitssystementwicklung.
14 CRS code 12110, gross disbursements in constant 2008 USD. Estimate made by key
informant.

ITALY
Health is one of six priority areas in official Italian
development policy 15 . In 2008, Italy committed USD 558.9
million to health ODA. Of all the countries in this review, Italy
has furthest to go to reach the WHO target of 0.1 % of GNI
to health aid, dedicating only a quarter of this amount (0.025
%) in 2008 16 .
In its global health policies, Italy promotes a horizontal
approach designed to ensure universal access and effective
and efficient health services. Between 2005 and 2009, Italy
claims to have made a bilateral contribution of USD 12.45
million to HRH 17 . Italy also purports to be actively supporting
health systems strengthening and human resources for
health by means of its contributions to multilateral
organisations such as the Global Fund, the WHO, UNAIDS
and UNFPA, which together receive the bulk of Italian
development funds, and by means of its involvement in the
International Health Partnership and related initiatives 18 . In
practice the share of funding devoted to health system
strengthening in multilateral organisations is quite variable.
Italy’s 2009 Guidelines for Cooperation in Global Health call
for “a level of human resources which are adequate both in
qualitative and quantitative terms referring to the public
health system needs” 19 . According to this framework,
human resources for health should have:
- Effective systems of training and on-going education
based on experience and best practices, which should be
taught using active learning;
- Salary, working conditions and adequate incentives,
which can thwart the unequal geographical distribution,
the mobility to the private sector, to the urban areas and to
foreign countries, also through the promotion of the
adoption of international codes aimed to regulate the
migration of human resources for health;
- Adequate professional improvement, supervision and
motivation.
The Guidelines also call for support, training and incentives
to increase the numbers of community health workers. Such
health workers are to be integrated into the national health
system and programmes must fit with the local cultural
context, in particular regarding reproductive health,
maternal, neonatal and child health, as well as the control of
communicable and non communicable diseases.
In November 2010, Italy signed a major partnership
agreement with Ethiopia to strengthen the health system
with EUR 8.2 million. The aim of the support is to increase
the coverage and quality of health services and also to boost
the capacity to generate and use strategic information.
Some 35 % of the contribution was allocated directly to the
Federal Ministry of Health as health budget support for the
MDG Fund. The Italian Development Agency has also
promoted South-South cooperation on HRH, such as
support for an agreement between Niger and Tunisia,
whereby Tunisia trains health professionals from Niger.
15 Source: 2010 Reality Check, Action for Global Health 2010.
16 Muskoka Accountability Report Annex 5, p. 40.
17 Promoting Global Health: L’Aquila G8 Health Experts’ Report 2009, pp31-32. Available here:
http://www.g8italia2009.it/static/G8_Allegato/G8%20Health%20Experts%20Report%20and%20Accou
ntability_30%2012%20%202009-%20FINAL%5B1%5D.pdf
18 MAE–DGCS: Salute globale: principi guida della cooperazione italiana, July 2009. Available at:
19 http://www.cooperazioneallosviluppo.esteri.it/pdgcs/italiano/LineeGuida/pdf/Principi.Guida_Sanita.pdf
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03 HOW DO MEMBER STATE DEVELOPMENT POLICIES
ADDRESS THE HRH CRISIS IN THE DEVELOPING WORLD
SPAIN
Comparative to its size economically, Spain is a generous
donor to global health ODA, providing a total of USD 688
million in 2008. Between 2005 and 2008, Spanish health
ODA increased from EUR 102 to EUR 496 million, with a
tripling of multilateral aid and an increase in bilateral aid from
EUR 130 to EUR 150 million 20 . However, even with these
aid increases, in terms of meeting the GNI commitment,
Spain is not even halfway at 0.045 % 21 .
Spanish development policy, including on health, is defined
by the ‘Master Plan’, a framework approved every four years
by Parliament. The current policy is based on the Primary
Health Care approach defined at Alma Ata and highlights
the importance of public health systems as crucial to the
attainment of the MDGs. The Master Plan 2009-2012
singles out the IHP+ as an initiative that can implement aid
effectiveness principles in order to strengthen health
systems. Of the six specific objectives on health, two are
directly connected to addressing the health care worker
shortage: Objective 1 focuses on the “formation,
consolidation and sustainability of effective and equitable
health systems”, while Objective 2 commits Spain to the
development of “sufficient and motivated human resources”.
The prominence of these two objectives at the beginning of
the report reflects the importance that Spain allocates to
these issues, at least on paper. However, there is no plan of
action on or any concrete amount of resources allocated to
fulfilling these aims.
The Spanish central administration argues that health
systems must be reinforced as a package, taking into
account the synergies and complex relationship between
the different health system components and that if one
sector is developed out of proportion with another this will
lead to dysfunction (for example, too many doctors but no
supplies). Spain regards general budget support to be the
best tool to fight the HRH shortfall and has committed to
allocate 60 % of bilateral aid to health system strengthening
under the principles of IHP+ by means of direct sector
budget support by 2012. However, since regional
authorities contribute half of Spain’s bilateral aid and they
are not committed to IHP+ principles, and there are no
mechanisms to coordinate different stakeholders to fulfil the
Master Plan, the 60 % goal will be extremely hard to reach.
Currently Spain contributes less than 11 % of all bilateral aid
to general budget support.
In addition to increasing funding available for
comprehensive health system strengthening, the Spanish
Agency for Development Cooperation (AECID) has
developed its first health sector plan that includes several
indicators on HRH strengthening for bilateral aid managed
by NGOs and has pledged that by 2013, 80 % of NGO
projects supported will include a component on training
health workers.
20 Central Administration Health AID Sectorial Diagnosis, December 2009.
21 Source: 2010 Reality Check, Action for Global Health 2010. Figures refer to 2008.
14

UNITED KINGDOM
The UK is the leading European donor to global health 22 . In
2009, the British Department for International Development
(DFID) allocated 15 % of total ODA, approximately EUR 1.5
billion, to improving health in developing countries.
However, this amount still falls short of the 0.1 % GNI target
set by the WHO, at only 0.058 % of GNI 23 .
The UK is one of the few countries with publically available
figures on the proportion of health ODA allocated to health
systems, and the only country to have completed a voluntary
scorecard on its progress to meet its IHP commitments 24 .
Between 2002/03 and 2008/09, DFID bilateral expenditure
on health systems increased from GBP 106 million to GBP
268 million. The share of total bilateral expenditure in health
allocated to health systems increased to 37 % in 2008/09 25 .
Although no exact figures are available, the UK claims to be
meeting the WHO target of 25 % of health aid towards
human resources for health strengthening 26 .
UK funding to health systems is channelled through a mixed
funding approach including bilateral programmes, direct
support to national health sector plans of partner countries,
and multilateral organisations and global funding
instruments such as the World Bank, and the Global Fund
for AIDS, TB and Malaria 27 . Some of the activities supported
include health staff salaries and retention schemes, preservice
education and training of health workers,
enhancement of skills among health workers and
productivity as well as management and supervision of
front-line workers.
In Sierra Leone, the UK is supporting the Ministry of Health
with improved workforce surveillance and strategic
intelligence, including a payroll review, and the training of
1,000 new health workers to meet the increased demand
created by the abolition of user fees. DFID has also provided
support to specific health worker initiatives, including the
Royal College of Obstetrician and Gynaecologist training
programmes in five target countries (three in Africa) and the
training of 12,000 midwives in Pakistan. In Ethiopia, DFID
has awarded GBP 25 million over four years to increase the
number of community health workers tenfold 28 .
DFID and the Department of Health jointly support the UK
International Health Links Funding Scheme, which provides
grants and support to health institutions across the UK,
allowing British health professionals to strengthen and
improve health worker capacity of partners in 10 developing
countries in Africa and Asia 29 . The Scheme has given out
over 30 grants to support long-term institutional
partnerships between UK organisations and their ‘Links’ in
the developing world. Building on the success of this
scheme, DFID is currently developing a new Health
Systems Partnership Fund to enable UK based health
workers to support human resources training in developing
countries. The programme will be funded up to GBP 5
million per year and will enable more British health
professionals to share their skills with midwives, nurses and
doctors in developing countries through teaching, training
and practical assistance.
22 Euromapping 2010, available at www.euroresources.org
23 Source: 2010 Reality Check, Action for Global Health 2010. Figures refer to 2008.
24 IHP scorecard available at: http://network.human-scale.net/groups/united-kingd
25 Health Portfolio Review, DFID 2009, p. 12. Available at:
http://www.dfid.gov.uk/Documents/publications1/health-portfolio-review-rpt-2009.pdf
26 Muskoka Accountability Report, Annex 5, G8, 2010.
27 DFID PQ response September 2010.
28 Muskoka Accountabiltiy Report, 2010.
29 DFID PQ response Sep 2010. See also http://www.thet.org/thet-launches-new-international-health-linksfunding-scheme
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03 HOW DO MEMBER STATE DEVELOPMENT POLICIES
ADDRESS THE HRH CRISIS IN THE DEVELOPING WORLD
COMPARISON OF THE RELATIVE STRENGTHS AND
WEAKNESSES OF THE FIVE COUNTRIES
COUNTRY
STRENGTHS
WEAKNESSES
FRANCE
Renewal of commitment and leadership
on health systems strengthening
ESTHER Twinning Programme
Strong policy commitments are not
translating into funding for health systems
Failure of HRH training initiatives
GERMANY
Support for health sector reform in 16
developing countries
Strong policy commitments are not
translating into funding for health systems
Lack of clarity on who will lead
implementation of the WHO Code
ITALY
Direct support to the MDG fund within the
health budget of Ethiopia
Renewal of commitment and leadership on
health systems strengthening at G8 summit
in 2009
The bulk of Italian ODA goes to vertical funds
Lagging behind other major donors on the 0.7
ODA and 0.1 health targets
SPAIN
Strong policy commitment to strengthen
public health systems (60 % of bilateral aid
via IHP+ by 2012)
The new AECID health plan includes several
HRH indicators: 80 % of NGO projects
funded by AECID in 2012 must include HRH
training.
The 60 % goal on health system
strengthening is unlikely to be met
Diversity of actors without adequate space for
suitable coordination, especially between
central and regional administrations
16
UK
Strong pre- and in-service training initiatives
including the new Health Systems
Partnership Fund
Relative transparency on progress towards
HRH and HSS goals (e.g. IHP scorecard)
The UK is a major source destination for
migrant health workers: action needs to be
taken to address the role of private
recruitment agencies.

The International Health
Partnership and related initiatives
(IHP+)
The International Health Partnership and related
initiatives (IHP+)
The International Health Partnership and related
initiatives (IHP+) was launched in September 2007
with the aim of better harmonizing donor funding
commitments, and improving the way international
agencies, donors and developing countries work
together to develop and implement national health
plans. The core concept is to mobilise donor countries
and other development partners around a single
country-led national health plan, guided by the
principles of the Paris Declaration on Aid Effectiveness
and the Accra Agenda for Action.
The IHP+ now includes 49 partners, including 24
developing countries. All of the five countries profiled in
this report are members of the IHP+.
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04 CASE STUDIES
MADAGASCAR: ACUTE
SHORTAGES OF HEALTH
WORKERS IN RURAL
AREAS
Coverage of health personnel in Madagascar is well below
the threshold recommended by the WHO (2.3 health
workers per 1,000 inhabitants) with approximately only 2
doctors and 3 nurses/midwives per 10,000 inhabitants 30 .
As such, the country is one of the 49 priority countries listed
by the WHO as needing greater support to strengthen the
health workforce.
The deficit of health workers in Madagascar occurs across
the whole country. However, health coverage is higher in
metropolitan and in urban areas than rural areas. Regional
differences in the distribution of health human resources are
significant and considerably weaken the health care system,
compromising the health of the population. Over 40 % of
the population live more than 5km away from a health facility.
According to the Ministry of Health, some 6,000 health care
professionals are ‘missing’. At the current pace it would take
at least six years to fill the number of positions required, not
including replacements for retirees and the proportion of
new graduates who turn to specialisation. To address this, it
will both be necessary to increase the number of health
workers trained each year, but also to increase the number
of positions available.
PHYSICIANS
TOTAL NEEDS
5068
AVAILABILITY
3988
MISSING
1080
The reasons for the shortage are familiar to most developing
countries. Less than 200 students graduate in general
medicine each year. The quota of graduates cannot be
increased due to the limited capacity of hospitals for
practical training. For budgetary reasons, not all these
trained staff are able to find positions in the national health
system. The exact unemployment rate of health personnel is
not known but it is estimated that there are high
unemployment rates among doctors in urban areas. The
ageing of the health workforce (nearly 50 % will retire within
10 years) and limited training capacity are aggravating
factors.
Most doctors in rural areas work seven days a week and
have little or no holidays. Doctors sent out to the bush do not
know how long they will stay there and if they will have
opportunities for advancement in their careers. There is no
salary increase from one year to another and staff poorly
paid. Health worker housing is situated far away from the
clinic and lacks electricity and water. Local schooling is
either not available or poor in quality. Some of the locations
are insecure and it can be dangerous for health workers to
go out at night, sometimes covering long distances. Older
physicians in particular are seeking more rewarding working
conditions and more comfortable living conditions for the
end of their career.
Medical students are required to spend the third year of their
studies abroad. Although measures have been taken to
penalise doctors who do not return home (including
disqualification from public service if they return) there is
anecdotal evidence, if not concrete statistical data, that the
brain drain, particularly to France, is significant. Many
Malagasy doctors move to France to become nurses and
caregivers in the private sector.
DENTISTS
147
80
67
PARAMEDICS
7627
6252
1375
ADMINISTRATIVE
STAFF
8796
5346
3450
Source: Feasibility study for the preparation of the health human resources
development plan, International Health Unit, University of Montreal 2009.
30 World Health Statistics, WHO 2010.
18

Efforts to change
Like 189 other countries, Madagascar has subscribed to the
Millennium Development Goals, with a series of targets to
be achieved by 2015. Health is a priority objective of the
government, as the third of eight commitments made by the
authorities as part of the Madagascar Action Plan for 2007-
2011. This document replaces the Poverty Reduction
Strategic Paper (PRSP) and gives directions for the
government’s general policies, including those related to
health.
The Development Plan for the Health Sector sets out
interventions and outcomes for 2011 in order to address key
challenges: staff shortages, inadequate distribution of
available staff, inadequate working conditions, weak
management systems, and inadequate initial and ongoing
training. Beyond the health sector, the Ministry of National
and Higher Education, the Ministry of Decentralization, the
Ministry of Finance and Budget are also concerned with
actions to develop to increase the coverage of HRH in the
whole country.
The Ministry of Health has pledged to produce a Plan for the
Development of Human Resources for Health (PDHRH),
supported by consultants from the Unit of International
Health at the University of Montreal. This team has been
working for several years on the development of this Plan by
providing studies documenting precisely the HRH situation
and proposing strategic priorities while evaluating the
technical and financial feasibility for the government. The
latest study was produced in February 2009. However, the
political context has changed since then, which threatens
the implementation of their final recommendations. The
Ministry plans to have the final Plan ready for January 2011.
The various projects initiated by the Ministry of Health to
promote the recruitment and retention of health workers in
rural areas range from modest incentives to the
development of a network of community health workers,
recruitment of private physicians and the extension of
coverage through the creation of health huts. The national
community-based health policy seeks to overcome the
shortage of HRH to ensure access to basic health services
to the community. In this way, the community level becomes
an extension of the health system. The policy relies on
community workers who have a kit of essential items
(including mosquito nets and contraceptives), to develop
awareness, detect possible signs of danger and to invite
patients to visit a health centre.
There are six training centres for paramedical students
training on average 350 students each year: in
Antananarivo, for example, about 120 paramedics graduate
every year, while in Sava it is between 30 and 40. The
relocation of the Training Institute for Paramedical of
Antananarivo in new premises in 2011 will allow it to take on
100 additional students, provided that the new institute is
also equipped with additional teaching resources. The
INSPC (National Institute for Public and Community-based
Health) is developing with the Ministry and the faculties of
medicine a new official diploma entitled ‘community-based
general practitioner’ that would recognise and value this
specialty.
However all these efforts need to be scaled up. Donor
support for HRH in Madagascar is very weak and poorly
coordinated, and NGOs involved in this subject are few and
far between. High turnover and poor management at the
Department for Human Resources at the Ministry of Health
have held back progress. Staff report being totally
overwhelmed with the management of personal requests
from health workers regarding their allocation. Although
serious efforts are underway in Madagascar to address the
critical shortage of health workers, the political crisis has led
to the suspension of aid from USAID, the World Bank and
the IMF.
Conclusion
A clear relationship exists between the health systems of
Madagascar and France. The implementation of the WHO
Code should result in a bilateral agreement between the two
countries to ensure that migration is well managed and that
both countries can benefit by circular migration. Such an
agreement will also need to address the resource needs of
the Ministry of Health as it attempts to develop its health
care workforce and reach rural areas. However in the
context of political instability and donor hesitance, the
prognosis for Madagascar is not good.
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04 CASE STUDIES
20
EL SALVADOR: PLENTY
OF DOCTORS, YET STILL
ON THE CRITICAL LIST
El Salvador is a country of contrasts. Despite being
classified as a middle income country, equality is a major
cause of concern: the UNDP human development reports
identify El Salvador alongside Guatemala and Brazil as one
of the most inequitable countries in Latin America, the
world’s most inequitable subcontinent. Although the
average income is USD 3,460 per year, the number of
Salvadoran households living in poverty has increased by 10
% during the last decade and more than 2.6 million people
live on less than two dollars per day 31 .
But El Salvador’s paradoxes are not limited just to wealth.
According to the WHO, El Salvador has a crisis in human
resources for health with only 12 doctors per 10,000
people. The Ministry of Health of El Salvador, calculates that
the average shortfall is at least 40 %. In 2008, as much as
53 % of the population had no access to health care.
However, the cause is not a lack of trained and prepared
professionals, because there are hundreds of doctors
qualifying every year and who are unable to find a position in
the public health system.
Public versus private
The problems with El Salvador’s health system and its
workforce stem principally from the Civil War in the 1980s.
For decades, the only place that Salvadorians could train to
become a doctor was in the public national university,
regarded as a source of opposition by the government and,
therefore, inadequately funded. Although the war ended
almost 20 years ago, the quality of education and medical
service still suffer from serious problems.
In El Salvador, doctors are perceived as elitist and removed
from the needs of real people. Some people are drawn to
the profession to gain prestige and money and the topic of
community medicine is derided and looked down on by
medical students. This image of a medical career is far from
the truth in a context in which the health budget has been at
no more than 2 % of GNI for many years. It also does
nothing to aid the recruitment of doctors to the rural and
poor communities where they are needed. A recent report
published by the WHO stated that since 70 % of nurses in
El Salvador believe that there is no opportunity for
advancement, or performance related pay at their
workplace, efforts to improve the motivation of health
workers need to be made a priority.
It is common in El Salvador for medical professionals to be
hired not by the day but by the hour. A typical doctor may
have two hours a day in a hospital and a few hours in a
private clinic to supplement his income. Esteban 32 , a human
resource manager of a private hospital in San Salvador,
remembers when he began to practice and how difficult it
was to find a work after spending 11 years studying
medicine. He recalled that many colleagues, after spending
the required year of voluntary work in a hospital, remained
working for free, waiting for a position and taking advantage
of the fact that “if a patient likes you, you can send him to
your clinic”. In this way, job insecurity is directly leading to
practices that undermine public health systems.
The Dr. Hugo Morán Quijada Health Centre provides
primary health care to 28,053 inhabitants living in the
municipalities of San Salvador and Mexicanos. It is open
from 7 a.m. to 7 p.m. during the week and it is visited by 700
patients per week. For this amount of hours and
consultations they have 20 doctors. The ratio of care should
be in the order of 35 patients per doctor. Unfortunately the
calculation is not so simple: 11 of the 20 doctors work just
two hours per day, six work only four hours a day and only
one is a full time member of staff. At tertiary hospitals, 60 %
of specialists work just two hours per day and predominantly
only in the mornings so that they can run private practice in
the afternoons. Of the 30 hospitals in El Salvador, 42.5 % of
doctors work only two hours per day, 25.8 % work for four
hours and less than 20 % are full time staff.
Although the country is small, much of the country is
mountainous and inaccessible and therefore has no health
service to speak of. Some 70 % of the consultations at
hospitals are primary care visits because there are no
resources at community level. Investment in primary care
has been low and patchy until very recently.
Four national health systems: a
prescription for disaster
El Salvador has traditionally had not one, but four national
public health systems. Each system has its own expenditure
per capita, distinct services and different pay-scales. The
first is operated by the Ministry of Health and intended to
cover all primary health, especially for the unemployed, the
poor and all those not covered by the other three health
systems. Per capita expenditure is only USD 87 per year.
Soldiers and teachers have their own health systems as part
of the benefits package and formal employees yet another.
Doctors can earn four times more working for the teacher
health system than the Ministry of Health. The Ministry of
31 El Salvador Annual Report, UNDP, 2009.
32 Names have been changed to protect identity.

Health can spend USD 87 per person per year, the social
security system USD 221 per year per person and the
teacher system can spend USD 340 per year. This results in
an extremely fragmented and dysfunctional system, in theory
overseen by the Ministry, but in practice left to its own
devices.
Although each system is financed separately, the Ministry of
Health remains responsible for covering the financial gap for
each of the other systems. The Ministry pays for all primary
care consultations for formal employees, soldiers and
teachers, without any compensation mechanism to recover
this funding. The result is that the Ministry, responsible for
providing care to almost 80 % of the population, has been
all but brought to its knees. El Salvador is therefore a good
example of ‘inverse care’, when people with the most means
– whose needs for health care are often less – consume the
most care, whereas those with the least means and greatest
health problems consume the least.
Reasons for hope: a brave new
Ministry of Health
After 20 years with one party in power, a change of
government has now put health at the forefront of the
political agenda. Dr. Maria Isabel Rodriguez, the new
Minister of Health of El Salvador, is a strong woman. The
former Dean of the School of Medicine at the National
University, Dr. Rodriguez is one of several ministers who
have made a courageous commitment to reform the national
health system to cover the 80 % of the population.
The President of El Salvador has charged the new Ministry
of Health to reach a budget of 5 % of GDP by 2014.
According to the Secretary of State for Public Health,
Eduardo Espinoza, “No country can achieve universal
coverage with less than 6 % of GDP; Costa Rica and
Panama are doing it, more less, with 5 %”. In 2008, the year
before the present Government took power, health
accounted for 1.8 % of the total budget with an expenditure
of USD 399.3 million. Notwithstanding the global economic
crisis, in 2009 the health budget has increased to USD 450
million, and in 2011 it is expected to exceed USD 517
million, or 2.4 % of GDP.
The budget increase will mainly be directed at a gradual
reform of the Primary Health Care system, which aims,
among other things, break the biggest barriers of health care
access of El Salvador, which are the rural-urban inequities.
To do this, a family medicine and health promotion model is
being proposed, carrying doctors and nurses to all
communities to reach out the half of the population that
today does not have regular access to health care.
In July 2010, health care reform started in the 63 poorest
municipalities of the country with the least access to health
facilities. Up to 10 of these municipalities had health
services fully managed by NGOs because of the weakness
of the state there. With the new model, health care will be
structured to cater for a group of up to 600 families, each of
whom will have access to a community health team made up
by a doctor, a nurse, a nursing assistant, three community
health workers and an ‘all-rounder’. There will be a family
doctor for every 3,000 people and a community health
worker for every 200 families. Every two groups of families
will have access to a psychologist and a nutritionist, and
other specialities will be accessible for each four groups of
families. By 2014 it is expected that this new system must
be operational in all municipalities.
Conclusion
The implementation of the WHO Code is unlikely to have a
major impact on El Salvador as the crisis is the result of a
chronic underinvestment in the health system. El Salvador is
pioneering a new way to deliver primary health care to its
people, with a potentially powerful model for achieving the
MDGs. So far, the World Bank and Latin American
Development Bank have made it possible for El Salvador to
increase the health budget. However, it remains to be seen if
the country can sustain the financing of salaries on the basis
of loans that must ultimately be repaid. International donors
have yet to step forward to support El Salvador in these
health reforms or to address specific problems with HRH
and health system strengthening. Since El Salvador is not a
low income country, it is unlikely to be high on the priority list
for assistance.
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05 GOING BEYOND THE CODE: NEXT STEPS
What will it cost
In 2006, the World Health Organisation estimated that
a USD 10 per capita increase in health expenditure
would be required to train and recruit missing health
workers. This would mean an average overall cost of
USD 136 million for training and USD 311 million for
employment.
The Task Force on Scaling up Education and Training
(2008) estimated that USD 26.4 billion would be
required over 10 years to train 1.5 million health workers
required in Africa.
Similarly, in their 2009 paper ‘Estimates of health care
professional shortages in Sub-Saharan Africa by 2015’,
Richard Scheffler et al. used forecast modeling to
conclude that USD 20 billion is needed to scale up
HRH in the region.
Source: Investing in health workforce: Efficiency and
effectiveness of aid flows, presentation by Dr. Gulin
Gedik, HRH Department, WHO, 16 March 2010.
The WHO has estimated that 25 % of all health spending
should be allocated to human resources for health.
Currently, very little information is known about the exact
spending of the five countries profiled in this report in this
area. It is almost impossible to gain accurate figures on the
exact amount of health aid allocated to HRH because this is
not captured in the spending breakdowns. As a matter of
urgency, Member States should make figures available on
how much ODA is being allocated to addressing the health
worker shortfall.
Experience has shown that piecemeal attempts to address
the HRH shortfall are likely to fail because the causes of the
crisis are multiple and complex. The measures promoted by
the WHO Code of Practice (no direct recruitment from
developing countries, bilateral agreements and circular
migration initiatives) are only a starting point. HRH spending
often represents over half of health ministries’ budgets and
is the single largest cost element in providing health
services in low income countries. However, HRH without
other inputs such as drugs and supplies, functioning
equipment, and adequate management, are ineffective 33 .
The cost of meeting the unmitigated international demand
for health care workers is increasingly being borne by the
world’s poorest nations. The growing consensus is that
national health systems in developing countries need to be
adequately resourced and that developing countries need to
have an evidence-based and well-resourced human
resource plan in place as part of their national health
strategies.
The following table summarises some of the major causes of
the human resources for health shortfall in developing
countries and proposed solutions that could support,
surround, or be incorporated within a national HRH plan.
22
33 WHO/Global Health Workforce Alliance 2009. Financing and Economic Aspects of Health Workforce
Scale-up and Improvement.

CAUSE
Governments cannot afford to pay staff, increase wages or improve
depressing working conditions, including poor facilities, equipment
and lack of essential medicines but also long hours and gender
based violence. In some countries, graduates cannot find
employment because there is no budget to hire them. HIV positive
health workers also face stigma and discrimination.
Tendency to fund health in a short term or vertical approach,
especially in response to emergencies such as HIV/AIDS.
Health budget ceilings and restraints on public sector salaries
imposed by IMF and World Bank in return for loans.
SOLUTIONS
Direct support to health sector budgets, investment in salaries,
management training, professional development and health systems
strengthening. Financing must be predictable, long-term and
sustainable.
Simultaneous expansion of health workforce as interventions are
scaled up. PEPFAR has introduced specific targets for training of
additional health workers.
Relaxation of macro-economic restraints to allow governments to
increase salaries and spend more on health. In Uganda, the
Parliament negotiated USD 30 million for maternal and child health
initiatives as a condition on a World Bank loan. The government of
Malawi negotiated an agreement with the IMF to increase health
care worker salaries.
Insufficient numbers of health care workers are being trained in
developing countries. Africa has a quarter of the number of medical
schools in Europe.
Jobs in the public health sector are regarded as too demanding and
poorly paid. Gender segregation of occupations is a major source
of inequality worldwide with implications for the development of
robust health workforces 34 .
About half of the global population lives in rural areas, yet more than
75 % of doctors and 60 % of nurses are found in urban areas 35 .
Health systems are not responsive to the needs of communities,
particularly vulnerable and marginalised groups.
Direct financial support to pre-service training institutions and
programmes. The Italian government has supported the medical
school in Liberia.
Redefine the nursing profession to include management skills and
practices usually only carried out by doctors. In Italy, male
recruitment to nursing schools increased when management was
included in the training programme.
Recruitment and retention schemes including financial and nonfinancial
incentives. Zambia offers a package of benefits to health
workers who commit to spending three years in rural communities.
Deployment of well trained, well paid and equipped community
health workers can both extend rural coverage and convey
community realities back to the health system. In Ethiopia, 33,000
‘health extension workers’ have been recruited in local villages.
However, this must not replace measures to increase numbers of
well-trained doctors, nurses and midwives.
Recruitment of health workers by the private sector, religious
organisations, and international NGOs resulting in brain drain from
the public sector.
Strictly monitored and enforced Codes of Conduct. A voluntary
NGO Code of Conduct for Health Systems Strengthening was
launched in 2008 to change practices that undermine Ministries of
Health in low income countries 36 . Donors and governments need to
both enforce and incentivize adherence to such Codes.
Lack of coordination between public and private health initiatives.
Increased communications and transparency between donors,
NGOs and Ministries. Map human resource capacity before
implementing health programmes.
Sources: Maximising Positive Synergies, WHO, 2009; Merchants of Labour, ILO, 2006;
Taking Stock: Health Worker Shortage and the Response to AIDS, WHO, 2006; A Critical
Shortage of Health Care Workers, Global Health Council, October 2007; Investing in
Health Workforce: Efficiency and effectiveness of aid flows, Presentation by Dr. Gulin
Gedik, HRH Department, WHO, 16 March 2010.
34 http://hrhresourcecenter.org/sg_gender
35 Taking Stock: health worker shortage and the response to AIDS, WHO, 2006.
36 Can NGOs help build the public-sector health workforce Health Alliance International, 2010.
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05 GOING BEYOND THE CODE: NEXT STEPS
Donors have been reluctant so far to take the step of paying
health care workers salaries directly, given the long-term
commitment this entails and the barrier of macro-economic
restraints imposed by loan conditions. However, the
growing interest in general budget support, has led to
greater calls for sector budget support (SBS) or in other
words, direct support to the health budget as a way to make
progress on the MDGs. In this way, donors come the
closest to compensating developing countries for the costs
they bear in training doctors and nurses for other countries.
Without strong investment in the health system of
developing countries, the push factors driving health worker
migration are unlikely to recede. Significantly, health sector
budget support must also be sufficiently long-term to ensure
sustainability and allow for the time-lag between medical
school recruitment and qualified doctors and nurses being
deployed.
According to the 2008 European Court of Auditors report
on EC Development Assistance to Health Services in Sub-
Saharan Africa, it has been European Commission policy to
provide technical assistance to strengthen priority sector
ministries as well as ministries of finance, approximately 10
% of General Budget Support (GBS) funding being
reserved for this purpose. However, in the 12 countries with
GBS examined by the Court, in only one case (Niger) were
funds allocated for specific technical assistance to the
Ministry of Health.
The advantages of providing both general and sector
budget support within the same country are that general
budget support allows for a broader political dialogue on a
wider range of issues that could address some of the
‘underlying principles’ and sector budget support enables
donors to participate in a more focused and effective policy
dialogue to monitor developments in a specific sector. As
health cuts across sectors, it is important that both
dialogues (the political dialogue within general budget
support and the sector dialogue within sector budget
support) link up and reinforce each other.
The IMF continues to support expenditure ceilings on health
budgets because they “help prevent overspending on
showcase projects”. However, the relaxation of macroeconomic
restraints to allow Ministries to increase public
sector wages has been successful in the case of Malawi,
where salaries were increased by topped up by 52 % (with
the increased income tax revenue providing income). In
Uganda, the Parliament negotiated USD 30 million for
maternal and child health initiatives as a condition on a
World Bank loan 37 .
Although the volume of aid to global health has increased
over past decades, the percentage share allocated to HRH
has been tiny. Donor responses have in part exacerbated
the trends, in so far as they have naturally responded to the
health emergencies of HIV/AIDS and other infectious
diseases with short-term approaches without the necessary
expansion on the health care workforce. For obvious
reasons, the strategy was to deploy existing workers, use
task shifting, and provide in-service training rather than the
longer-term effort of training new health workers. In some
cases incentives used to achieve project goals have had
repercussions for the local labour market, such as
volunteers receiving more in allowances than nurses receive
in salaries 38 . In others, imbalances between rural and urban
workforces have been exacerbated 39 .
Increasingly, global health initiatives and multilateral actors
such as the Global Fund and PEPFAR, are recognising the
importance of maximising their contributions to health
workforce strengthening and introducing targets for the
training of health workers. In Malawi, the government reallocated
a major grant from the Global Fund to support its
Emergency Human Resource Programme, increasing the
numbers of staff across all levels of the health system as a
result 40 .
24
37 WHO/Global Health Workforce Alliance 2009. Financing and Economic Aspects of
Health Workforce Scale-up and Improvement.
38 Centre for Global Development, Zeroing In: AIDS Donors and Africa’s Health
Workforce, 2010.
39 WHO, Maximising positive synergies between health systems and global health
initiatives, 2009.
40 R. Brugha et al., Health Workforce responses to global health initiatives funding: a
comparison of Malawi and Zambia, Human Resources for Health, 2010.

It is not only global health initiatives that need to question
their actions. In recent years the number of NGOs active in
supporting global health has grown exponentially, especially
in Africa. Research by AfGH in Zambia has revealed that
high salaries offered by NGOs have had a detrimental effect
on the ability of the national health system to recruit staff to
rural areas 41 . In increasing recognition of the role that
international NGOs (often in response to donor demands
for quick and tangible results) are inadvertently playing in
worsening the HRH crisis, a group of six NGOs launched a
voluntary NGO Code of Conduct for Health Systems
Strengthening in 2008 42 . The 50 signatories of the Code to
date have pledged to avoid hiring health or managerial
professionals from the local public sector, and to work
towards fair salary structures in all sectors of the health care
system, including community health workers. The document
also urges NGOs to invest in education and training as a
way to compensate for the workers that they hire and to
coordinate planning with Ministries of Health 43 .
In an evaluation of the implementation of the Code in May
2010, Health Alliance International highlighted some of the
best practices of NGOs in this regard. Most NGOs are no
longer hiring expatriates when local personnel are available
and do not hire people from the public sector unless it is first
approved by the Ministry of Health. Some NGOs have
adjusted their pay scales to match those of the local
government and university salaries. Others are working
directly with universities to train doctors and nurses, thus
preparing them for a primary health care role 44 . Donors have
a role to play in supporting these initiatives and incentivising
adherence to the NGO Code.
41 AfGH, Zambia: Aid Effectiveness in the Health Sector, 2009.
42 http://ngocodeofconduct.org
43 N.Bristol, NGO Code of Conduct hopes to stem internal brain drain, The Lancet,
Volume 371, Issue 9631, p.2162, June 2008. Available at:
http://www.thelancet.com/journals/lancet/article/PIIS014067360860937X/fulltext
44 Health Alliance International, Can NGOs held build the public-sector health workforce
Successes and Challenges implementing the NGO Code of Conduct for Health
Systems Strengthening, 2010. Available at: http://ngocodeofconduct.org/wpcontent/uploads/implementing_ngo_code_of_conduct_report_may-2010.pdf
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06 ARE MEMBER STATE DOMESTIC HEALTH POLICIES
ADDRESSING THE HRH CRISIS IN THE DEVELOPING WORLD
FRANCE
France provides a national health service funded largely by
health insurance. In 2000, the WHO rated French health
care as the best in the world. According to the latest figures,
French national expenditure on health is the highest of all the
AfGH countries reviewed in this report at USD 4,627 per
capita.
France has a total of 227,683 doctors and 494,895 nurses
according to the WHO, placing it on a par with the
European average in terms of density of health care
professionals. However, France has a severe shortage of
midwives, particularly in rural and disadvantaged areas.
There are fewer midwives in France than in the UK but more
births: 20,000 midwives per 800,000 births in France
against 35,000 midwives per 650,000 births in the UK.
In an attempt to reduce health service costs in the 1980s,
France dramatically reduced the number of medical
students permitted to qualify as midwives and doctors.
Currently only 1,000 midwives are permitted to graduate
each year. Of these, dozens will never exercise their
profession, either unmotivated by the unattractive wages,
conditions in maternity units or the lack of opportunities for
professional development. The major outcome of this quota
policy has been a halving of the numbers of trained GPs and
specialists as well as a halving of the number of interns in
hospitals, who provide the bulk of emergency and continuity
of care. The remaining vacant positions, especially in
peripheral hospitals and in rural areas, have gradually been
occupied by doctors with non-EU qualifications. These
doctors are not permitted to practice all aspects of medicine
and are paid 40 % less than EU qualified doctors on a salary
only just above the minimum wage.
Although France is now training health care professionals in
greater numbers, it may be a case of too little too late.
According to estimates by the Ministry of Health the number
of doctors in France will decline nearly 10 % over the next
decade. Between 2006 and 2030, the French population is
expected to grow by approximately 10 %, with more births,
an increasingly ageing population and high medical
expenses. Even with the raising of the quota on how many
doctors are permitted to qualify to 8,000 each year, the
current level of density will not be regained until 2030.
Official projections show that the density of doctors will
decrease from 37 per 10,000 to 27 per 10,000 by 2020,
creating a critical situation for the provision of care,
especially in rural areas. As in Spain and Germany, newly
qualified doctors prefer to practice in urban centres or
privately. Even today, 2.3 million French people live in areas
considered as “in difficulty or fragile in terms of medical
presence”.
Overseas recruitment
In 2007 France employed 7,966 doctors who were not
French citizens (3.5 % of all physicians). Of these, 53 % are
Europeans (Belgians, Germans, Italians), while the rest are
non-European, mainly from the Maghreb (Algeria, Morocco,
Tunisia). Foreign-trained doctors and nurses are primarily
employed in hospitals.
Most of France’s foreign-trained health workers are from the
EU. International recruitment of doctors and nurses without
EU qualifications to both public and private practice was
prohibited in 1999, with the exception of refugees and
asylum seekers. Only nurses with EU diplomas are
permitted to practice. However, there are no such
restrictions on recruiting foreign trained pharmacists and
certain health facilities do manage to circumvent this
legislation. The strategies being employed to address the
current and impending staff shortages are focused on
addressing the retirement age, co-operation between
hospitals and incentives to encourage health professionals
to work in underserved areas 45 .
26
45 OECD Health Working Papers No. 36, Projet OECD Sur La Migration Des
Professionnels De Santé: le cas de la France, DELSA/ELSA/WP2/HEA(2008)3.

Coherence
France has taken a number of steps to address the
anticipated HRH crisis. Quotas have been raised since
2002 on the number of students in medicine, dentistry,
pharmacy and nursing. Training and financial support to
increase the retention of health staff in the hardest hit areas
have been accompanied by efficiency measures using ICTs,
task shifting and new outpatient services. Doctors have
been allowed to continue to practice medicine after
retirement. Grants have also been made available to support
foreign medical students that wish to return home or who
wish to participate in North-South networks in higher
education and research.
In 2008, the French government set up an inter-ministerial
platform for HRH, gathering representatives from the
Ministries of Health, Foreign Affairs, Immigration, Education,
Development (AFD) and the main relevant organisations:
bar councils for physicians, midwives, universities and
representatives of the civil society. This platform aims at
sharing experience among French actors and assesses the
different actions undertaken on the issue of HRH.
Conclusion
With the exception of midwives, densities of health workers
in France are not yet presenting major problems. However,
the country needs to rapidly take action to ensure a well
balanced coverage of the health workforce is maintained
throughout the whole territory, especially in rural areas. A
better understanding of the enter and exit flows of health
workers including foreign staff would also help to plan
efficiently the actions needed to address any future
shortage in specific health professions such as midwives
and other specialists.
Strengths
• Inter-ministerial platform enables coordination between
Ministries and bodes well for implementation of the WHO
Code.
• Steps are being taken to prevent a future crisis, including
the raising of quotas on medical school entrances.
Weaknesses
• Legislation designed to reduce the possibility of health
workers being recruited from developing country health
systems is being circumvented by private agencies.
• Working conditions especially for midwives and general
practitioners need to be dramatically improved as a matter of
urgency in order to attract new recruits.
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06 ARE MEMBER STATE DOMESTIC HEALTH POLICIES
ADDRESSING THE HRH CRISIS IN THE DEVELOPING WORLD
GERMANY
Germany has Europe’s oldest universal health care system,
dating back to 1883. Over 10 % of the national budget is
allocated to health, equivalent to USD 4,200 per capita 46 .
On paper, Germany fares well in terms of ratios of doctors
and nurses to population, with densities above the EU
average. Despite this high coverage, recent estimates
suggest that approximately 17,000 full-time physicians were
lacking in 2010; this shortage will rise to 56,000 in 2020
and 166,000 in 2030. For health workers other than doctors
there was even a slight ‘oversupply’ of 30,000 health staff in
2010. However, a shortage of about 14,000 full time staff is
predicted by 2020, rising to 786,000 in 2030 47 . Germany is
predominantly a source country for health worker migration.
Significant numbers of German doctors and nurses are
migrating to Scandinavia, Switzerland, the US, but also both
Italy and France, as documented in these country’s profiles.
Overseas recruitment
Currently there is no recruitment of health workers from
abroad. Nurses from non-EU countries can technically only
be granted a German work permit if the Federal Employment
Agency has concluded a placement agreement with their
home country (currently only the case for Croatia). Highlyskilled
employees (including in the health sector) can
receive a work permit if they can prove an annual income of
at least EUR 63,000. Under this rule, only medical doctors
and other health specialists can presently qualify for a
German work permit.
Nonetheless, 11 % of all physicians and 10 % of nurses
working in Germany have been trained overseas. In 2006,
4.5 % of all employees working in the health sector were
foreign nationals and 4.6 % naturalized citizens. The share
of foreign nationals was lowest in the profession of medical
doctors (3.9 %) and highest for less qualified positions such
as nursing and geriatric nursing assistants (6.1 %) 48 .
Although Germany does not actively recruit foreign health
workers, projections indicate that this will change in the near
future and that proactive policy making is required to avoid a
critical shortage. As a response to the anticipated skilled
worker shortage in health and other sectors, the German
government is currently developing a new policy for
recruiting workers from non-EU countries and for
accrediting foreign certificates and degrees 49 .
Coherence
While the Ministry of Health led negotiations on the WHO
Code of Practice, various institutions will be involved in its
implementation, including the Ministry of Labour and Social
Affairs, the Ministry of the Interior, the Federal Office for
Migration and Refugees and the Development Ministry
(BMZ). The BMZ contributes to overcoming the shortfall of
health workers in developing countries through its
development programmes (see above). The regulation of the
recruitment of foreign health workers for domestic health
care is an interagency topic which touches labour market,
health and immigration policy issues.
Until now, no concrete action has been taken by the relevant
ministries. Coordination among the ministries is in its infancy
at best; there is no interagency working group and it is
unclear who exactly in the Ministry of Health will take the
lead in implementing the WHO Code of Practice. This also
applies to measures currently being discussed under the
notion of ‘circular migration’, which refers to temporary
employment and training of foreign health workers in
Germany and temporary deployment of German health
professionals in developing countries. The idea is to address
urgent, short-term needs for health personnel in developing
countries through this approach while, at the same time,
training foreign health professionals in Germany to fill the
HRH gap in these countries in the medium term. It is
currently unclear which position the German government
take in relation to circular migration, and how related
exchange and training programs will be taken forward.
28
46 World Health Statistics, WHO, 2010.
47 Dennis A. Ostwald, Tobias Ehrhard, Friedrich Bruntsch, Harald Schmidt and Corinna
Friedl, 2010: Fachkräftemangel: Stationärer und ambulanter Bereich bis zum Jahr
2030, edited by PricewaterhouseCoopers AG Wirtschaftsprufungsgesellschaft,
Frankfurt am Main, p.35-38.
48 Anja Afentakis and Karin Böhm 2009: Beschäftigte im Gesundheitswesen.
Gesundheitsberichterstattung des Bundes, Heft 46, edited by Robert Koch-Institut,
Berlin.
49 Spiegel Online, 20 October 2010;
http://www.spiegel.de/politik/deutschland/0,1518,725775,00.html

Conclusion
While there is no imminent crisis, Germany needs to rapidly
take action to establish interagency coordination structures
which will allow the development of policies and tools to
implement the WHO Code, and to avoid the severe
shortage of German health workers looming on the horizon.
Strengths
• Germany already has strong legislation in place to ensure
international recruitment is managed jointly with the source
country.
• Discussions are already underway on how to integrate
migrants into the health system in an equitable way.
Weaknesses
• Currently, coordination between government agencies is
weak.
• Retention measures need to be taken to prevent German
doctors migrating, and to incentivise them to take up rural
posts.
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06 ARE MEMBER STATE DOMESTIC HEALTH POLICIES
ADDRESSING THE HRH CRISIS IN THE DEVELOPING WORLD
ITALY
The Italian National Health Service was established in 1978
and aims at granting universal access to a uniform level of
care throughout the country, financed by general taxation.
The system is decentralised and managed at the regional
level. In 2007, Italy’s total expenditure on health amounted to
8.7 % of GDP 50 . Universal health coverage has been
achieved, although regions widely differ in terms of health
care quality and health expenditure, with a clear North-
South divide.
Italy has traditionally ranked very high globally in the WHO
rankings on doctor patient ratios, a few years ago second
only to Cuba in terms of the number of doctors it produces.
Currently, there are 215,000 doctors in Italy, giving a ratio of
37 per 10,000 people, similar to that in Germany and
France. In Italy however, the number of doctors is surplus to
government requirements. Competition for public service is
fierce, with newly qualified doctors typically facing a long job
search before finding regular employment. Nevertheless,
Italy will face a shortage of highly specialised doctors in the
near future. In fact there is a shortage of qualified specialists
in certain sectors, such as anaesthesia and radiology. In
paediatrics, the number is expected to halve from 2015 to
2030 if the current enrolment and turnover trends continue.
This shortage could result in a lack of 50,000 specialists in
the next five years.
While Italy trains more physicians than it needs, it does not
train enough nurses to meet current demand. Every year,
17,000 nurses retire and only 8,000 enter the field 51 .
According to the Italian Federation for professional nurses,
health assistants and childcare workers (IPASVI), there were
364,663 professional nurses (6.1 nurses for every 1,000
habitants) at the end of 2009. There are different estimates
of the size of this national shortage, but all estimates place it
above 50,000 nurses 52 . The main sectors affected are
emergency care and hospitals, especially during holiday
periods.
The causes of the nursing shortage are attributed to several
main factors. In the 1990s, health expenditures were put
under strict control and since 2005 the budget for human
resources has been reduced by 9 %. There has been a lack
of investment in training sufficient numbers of health care
workers to meet the needs of an ageing population. There
are also strong limitations on access to medical schools
increasing trend towards specialization away from primary
health care and high retirement rates. As is the case in most
countries, nursing is regarded as an extension of the
women’s traditional role in society and not a role that is
highly respected and remunerated. In order to make nursing
more attractive as a career some hospitals recently
introduced management training into nursing courses,
resulting in a large increase in applications from men.
Overseas recruitment
About 4.4 % of all physicians in Italy were born abroad, an
increase of 1 % since 2004 53 . A much larger proportion,
28.4 % of nurses registered with the Italian Nursing
Federation are from outside Italy. Very few of the foreign
born doctors in Italy are from developing countries. The
majority are now from Europe and since the fall of the Berlin
Wall, increasingly from the former Soviet Union 54 . With
nurses however the picture is very different. A far greater
proportion of foreign nurses come from outside the EU, with
a notable proportion from developing countries such as
Peru and India, both countries that are on the WHO critical
list of countries with a density of health workers below a
critical threshold to achieve an 80 % coverage rate for
skilled birth attendance and child immunisation 55 .
Doctors and nurses from outside of the EU face
considerable barriers to practice medicine in Italy, since
citizenship is almost essential for a successful career in the
public sector. Access to specialization, for example, is
limited for non-EU citizens even if their medical degree is
Italian. Another important obstacle for foreign doctors is the
language barrier, since Italian is not widely spoken abroad.
Some 80 % of the members of the main association of
foreign doctors (AMSI) were trained in Italy.
50 http://ec.europa.eu/health/ph_information/dissemination/echi/echi_25_en.pdf
51 Chaloff, J. (2008), ‘Mismatches in the Formal Sector, Expansion of the Informal Sector:
Immigration of Health Professionals to Italy’, OECD Health Working Papers, No. 34.
52 Data from ‘Dossier statistico immigrazione Caritas/Migrantes’ quoted in
http://www.stranieriinitalia.it/briguglio/immigrazione-e-asilo/2006/aprile/scheda-ricsim-infermieri.html
53 Il Sole 24 Ore, 20/09/2010.
54 Il Sole 24 Ore, 20/09/2010.
55 http://infocooperation.org/hss/documents/s15627e/s15627e.pdf
30

Coherence
The acute nursing shortage in Italy first led Italian policy
makers to establish exemptions for nurses within the annual
ceilings (2,000 nurses in 2001) and then to enshrine a
permanent exemption from quotas in migration law in 2002.
According to this regulation, only professional nurses are
exempt from migration quotas and can be offered a
permanent job in Italy. In 2005, of the 7,000 foreign nurses
working in Italy, most were in the private sector. Some of
these nurses later try to make the leap to the public sector 56 .
Some Italian regions recruit nurses from Eastern European
countries such as Romania through bilateral programmes
with nursing training institutes. Recruitment of nurses from
abroad was particularly intense during the 1990s when the
shortages were acute. According to a report by Bocconi
University in 2005, eight employment agencies were active
in the nurse recruitment sector, of which six provided only
foreign health personnel, relying directly in international
recruitment 57 . Agencies offer language and training courses,
both before and after leaving the home country, and often
provide housing assistance. However more recently, the
need to recruit internationally has been considerably
alleviated by increasing numbers of Italian students entering
in nursing schools, encouraged by the raising of enrolment
quotas.
Conclusion
The Italian public health system is feeling the strain due to a
legacy of past policies and inadequate forward planning.
The decentralised system is already reliant on nurses from
countries in desperate need of them, who form in some
cases a ‘second class’ tier of the health service in Italy
because they are often recruited by private agencies. There
remains a great deal for Italy to do in order to implement the
WHO Code and ensure that the requisite growth of the
national health service does not have a negative impact on
the attainment of the MDGs.
Strengths
• The system for training, recruiting and retaining physicians
in Italy appears to be functioning well.
• Measures are being taken, albeit slowly, to increase the
numbers of nurses entering the profession.
Weaknesses
• Italy is unlikely to resolve its impending HRH crisis unless it
increases investment in the health system overall.
• Domestic and foreign policy on human resources for health
are in conflict. The implementation of the WHO Code
presents a timely opportunity to bring them into alignment.
56 Chaloff, J. (2008), ‘Mismatches in the Formal Sector, Expansion of the Informal Sector:
Immigration of Health Professionals to Italy’, OECD Health Working Papers, No. 34.
57 ‘Politiche Migratorie, lavoratori qualificati, settore sanitario. Primo Rapporto EMN Italia’
a cura di IDOS-Punto di Contatto dell’EMN, con il supporto della Direzione Centrale
Immigrazione e Asilo del Ministero dell’Interno.
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06 ARE MEMBER STATE DOMESTIC HEALTH POLICIES
ADDRESSING THE HRH CRISIS IN THE DEVELOPING WORLD
SPAIN
The Spanish National Health System in its current form was
constituted in 1986 and decentralised in 2002. In 2008,
national expenditure on health was only USD 2,700 per
capita, the lowest contribution of all five EU Member States
reviewed in this report 58 . As a percentage of GDP, the
budget was 8.5 % – slightly above the UK and slightly
below Italy.
Spain is below the EU average for density of doctors and
nurses, with 21 doctors and 74 nurses/ midwives per
10,000 people. Currently, Spain has a deficit of 9,000
doctors. The shortage is acute among family doctors in rural
areas, anaesthetists, paediatricians, radiologists,
psychiatrists and gynaecologists. If current trends continue,
the shortfall will be 25,000 doctors by 2025.
Reasons for the shortfall
Since the year 2000, the Spanish population has increased
by six million, without a proportional expansion of the health
budget. Spain has the second highest life expectancy in
Europe, at 81 years and people over the age of 65
constitute over 16 % of the population. The health care they
require is labour intensive and likely to be long term.
In 1983, Spain topped the European league tables for the
number of qualifying medical students. However there was a
shortage of residencies available for students to complete
their training.
One of the consequences of the high levels of
unemployment among doctors has been a deterioration in
terms and working conditions as there was more people
willing to work even for worst conditions. In relation to this,
working conditions within the public sector have made the
profession much less attractive to potential students.
Meanwhile, the establishment of quotas on the number of
new students allowed to train has left the country
unprepared for increasing health demands of the
population.
In 1992, Spain decentralized the health system and the
autonomous communities invested considerably in health
facilities and services, without making parallel increases in
the numbers of new doctors and nurses. For example,
primary health care professionals now represent 38 % of the
total health staff but cater for 90 % of the population’s health
problems. In 10 years the number of primary health care
personnel has decreased by 10 % while consultations have
increased by 45 % 59 .
This has led to competition for professionals across the 17
autonomous regions without any coordination to avoid the
inevitable shortfalls and inequities across regions. In 2003,
legislation was introduced to standardise the labour market
and to introduce a register, without success.
Due to the problems with the labour market, many of Spain’s
trained health workers have moved to Portugal or the UK,
where conditions are relatively more attractive.
Approximately 8,000 Spanish health professionals work
abroad 60 and the efforts put in place to promote volunteer
return have so far been unsuccessful 61 .
Overseas recruitment
Spanish legislation allows a maximum of 10 % of non-EU
doctors in new residency positions. However, there is no
limit for those already studying in Spain or who have a
residence permit. The system does not capture how many of
them studied medicine in their own country. Since Spain has
no centralised register of its health personnel, there is no
way to know exactly how many health professionals are from
abroad. However, according to the Madrilenian Medical
Association, it is estimated that the number of foreign
professional doubled between 2002 and 2006 and that in
2010, 50 % of the resident positions were occupied by
students from outside the EU. Foreign doctors fill positions
that Spanish health workers have left, especially as rural
doctors. Due to a common language, most of them come
from Central America or the Caribbean, although a growing
proportion are from Eastern Europe.
58 World Health Statistics, WHO, 2010.
59 According to the Spanish Society of Communitarian and Family Medicine.
60 Madrid Medical Association
61 The Return Plan attracts just 14 professionals, Público, 26/4/2010.
32

Coherence
Although there is no official public policy to recruit health
workers from abroad, health managers are able to exploit a
loophole in the legislation to enable this in practice. Job
descriptions can be written to include specific skills that
national applicants are unlikely to have and entered into a
“catalogue of occupations of difficult coverage”. This makes
it possible to justify the hiring of a non-EU health worker.
Each of the autonomous communities has one such list
updated each quarter. During the last quarter of 2010, nine
communities requested foreign workers via the catalogue –
eight of them requested health professionals (mainly general
practitioners) and four of them exclusively requested health
workers 62 .
Conclusion
Spain is a good example of the effects of increasing
international migration both in terms of the brain drain of its
own health professionals to other countries and the
temptation to take the easiest option to recruit personnel
rather than address the root cause. Legislation to restrict
recruitment from overseas is ineffective, regions compete
with one another for staff and efforts to limit emigration have
been so far unsuccessful. As one of the few EU Member
States with a growing population, it is urgent that Spain
places more effort into resolving these problems, starting
with the collection of national statistics and implementation
of the WHO Code.
Strengths
• Spain brought in positive legislation on the management of
health professionals in 2003 that would greatly improve
the situation if it was implemented.
• Awareness of the scale of the HRH shortage in Spain is
increasing and restrictions on the number of students
entering medical training are gradually being lifted.
Weaknesses
• The Government has no centralised register of health
personnel working in the country and thus no way of
managing the situation.
• Spain is currently implementing drastic cuts in public
services that are likely to exacerbate shortages in health
personnel.
62 Calculation based on the ‘Catálogo de ocupaciones de difícil cobertura 3º trimestre de
2010’, INEM.
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8
© LILIANA MARCOS / FPFE
06 ARE MEMBER STATE DOMESTIC HEALTH POLICIES
ADDRESSING THE HRH CRISIS IN THE DEVELOPING WORLD
34
UNITED KINGDOM
The British National Health Service (NHS) was established
in 1948. A recent study found that the UK is the only country
in the industrialised world where wealth does not determine
access to health care 63 . Nonetheless, in 2007 the UK had
the lowest per capita spending on health as a percentage of
GDP, at just 8.4 % 64 . The NHS is funded by taxation.
Compared with its peers, the UK also has far fewer doctors
and nurses. The ratio of doctors to population is just 21 per
10,000 65 . There are currently over 200,000 registered
doctors working in the UK according to the British Medical
Association 66 .
Overseas recruitment
Historically, the UK has always sourced nurses and health
professionals from developing countries. As early as 1950s,
two years after the NHS was established, nurses were
recruited from the Commonwealth 67 . In the year 2000, the
UK embarked on intensive international recruitment of health
professionals following a directive from Department of
Health to address personnel shortages. This staffing ‘stock
up’ saw an active recruitment of health workers from the
Philippines, India, South Africa and other Commonwealth
countries. The recruitment of health workers was closely
linked to English-speaking countries, those with historical
ties to the UK, or where the UK has played a major role in
development, supporting health systems of those countries
through various initiatives including training doctors and
nurses, construction and maintenance of health
infrastructure and health policies.
In 2007, a Government commissioned report estimated that
“at end of 2005 around 30 % of UK doctors and 10 % of its
nurses had received their initial training overseas” 68 . The
most recent UK NGO Migration Watch assessment of
foreign health workers (2009) claims that there are currently
645,000 foreign nurses registered in the UK, of which
300,000 are working in the NHS, while 200,000 are
working in private sector and the 145,000 are not
practicing 69 . It is not possible to identify all the countries
where nurses originate, however the main source countries
are India, the Philippines, Australia, South Africa, Nigeria,
the West Indies and Member States of the European Union.
UK Code of Practice
In 1999 the UK introduced its first guidelines on the
international recruitment of health care workers in
recognition that the health systems in South Africa and the
West Indies were being negatively affected. A Code of
Practice for international recruitment for National Health
Service (NHS) employers was introduced in 2001 and
strengthened in 2004, and now covers all private
recruitment agencies but not private sector employers 70 .
The purposes of the code of recruitment were to prevent the
NHS employers from active recruitment of international
health personnel; however the code allows international
recruitment of health workforce through government to
government agreement.
The Code has been controversial, with some studies
showing no impact on the arrival of nurses from Africa since
its introduction, and others showing that Caribbean nurses
simply move to the US instead. An estimated 7,000 foreign
nurses registered to work in Britain in 2005 alone. The Code
also does not prevent private agencies recruiting personnel
into private care homes, from which they can enter the NHS
at a later date 71 .
There is considerable overlap between the UK Code of
Practice and the new WHO Code of Practice, with
additional requirements on data collection, research and
information exchange. The UK Department of Health already
has in place a monitoring system to ensure that all
recruitment agencies adhere to the Code, which may form a
basis for other member states to emulate. In the UK
responsibility for reporting on the WHO Code is shared
between the Department of Health and DFID.
63 The Commonwealth Fund, 2010.
64 World Health Statistics, WHO, 2010.
65 World Health Statistics, WHO, 2010.
66 As per BMA website: http://www.bma.org.uk/patients_public/checkingdocreg.jsp
67 Buchanon J et al. (2006), Royal College of Nursing report to the Commonwealth on
nurse migration.
68 Crisp, N. 2007, Global Health Partnerships: The UK Contribution to Health in
Developing Countries. Available at:
http://www.suht.soton.ac.uk/sohmed/Crisp_report.pdf
69 Migration Watch, Immigration: The need for foreign nurses. Available at:
http://www.migrationwatchuk.org/Briefingpaper/document/45
70 Merchants of Medical Care: Recruiting agencies in the global health care chain, John
Connell and Barbara Stilwell, in: Merchants of Labour, ILO, 2006.
71 Ibid.

Conclusion
The UK has traditionally depended on overseas recruitment
to staff its national health service. However it was only in the
late 1990s that the impact of this on fragile health systems
in developing countries was recognised. Efforts to ensure
that such recruitment is ethical and in harmony with
development policy have been only partially successful
given the expansion in the number of private recruitment
agencies that enable migrants to enter the NHS ‘via the
back door’. This highlights the limitations of Codes of
Practice.
Strengths
• The existence of the UK Code of Practice and a decade of
experience in its implementation gives the UK a head start
in terms of delivering on the WHO Code of Practice.
• The Government has pledged to preserve the NHS budget
even as other public services are subject to major cuts.
Weaknesses
• Due in part to colonial ties and NHS history, the UK is
unlikely to change its status as a popular destination for
migrant health workers.
• Until there is better regulation of private recruitment
agencies, they will continue to stimulate migration in the
developing world and exploit health care workers.
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© SIEGFRIED MODOLA/IRIN
07 CONCLUSION AND RECOMMENDATIONS
It has been clear for many years that there are insufficient
numbers of health workers in the world to meet the needs of
the population, and not even to meet the minimum standards
enshrined in the health MDG targets. As the cases of El
Salvador and Madagascar show, for too long governments
and the international community have overlooked the basic
fact that health systems cannot function without health
workers. European Member States have been able to
assume that their own shortages will be met by means of
immigration, without considering the impact down the care
chain.
In this bizarre system, fully trained doctors find it preferable
to relocate across continents at their own expense to take
up positions that they are overqualified for. Strategies are
made to provide dispensaries in every village, with no plans
for who will prescribe. Incentive schemes are drawn up to
encourage women to move to rural areas, where there are
no jobs for their partners, and no schools for their children 72 .
The pace and scope of global health migration is increasing
year on year. On the one hand, EU Member States are
ostensibly boosting the health workforce in developing
countries. On the other hand, they are taking the very same
workforce away. The net result is that the beneficiaries of
this manifestation of globalisation are almost exclusively rich
nations, with poor countries, and naturally, the poorest of the
poor, bearing the costs.
In a globalised world it is impossible to separate national or
EU-wide actions from global policy, as global health issues
have an impact on internal EU health policy and vice versa.
The time has come for the EU and its Member States to
ensure coherence between their internal and external health
policies in attaining global health goals including the MDGs,
the European Consensus on Development Cooperation and
the 2005 Paris Declaration on Aid Effectiveness –
particularly as they prepare for the High Level Forum in
Seoul.
The five countries profiled in this report share a number of
challenges and barriers to efficiently support the
strengthening of the global health workforce in order to
meet the health MDGs. In order to honour their pledges
both in terms of quality and quantity of aid, donor countries
should pay particular attention to the following areas:
Development Cooperation Policy
As donors, EU Member States should:
1
2
3
4
5
6
Ensure that 50 % of all new funding for health is directed
towards health system strengthening, with 25 %
impacting directly on the retention and training of HRH,
in line with WHO recommendations. Financing must be
predictable, long-term and sustainable to allow for
forward planning by Ministries of Health.
In line with the Kampala Declaration and Agenda for
Action, support the development and implementation of
comprehensive, evidence- and needs-based, fully
costed and funded national health plans and
related health workforce strategies. Additionally,
they should pay particular attention to populations,
groups or contexts where access to qualified health
workers is challenging, including to women and
adolescents, vulnerable and marginalized groups,
discriminated populations, in rural or remote areas, and
in fragile states.
Commit financially and politically to the global target
for the training, deployment and management of at least
3.5 million new health workers by 2015 in countries
with an acute shortage. Where appropriate, they should
include the deployment of well trained, well paid and
equipped community-based health workers alongside
professional doctors, nurses and midwives.
Ensure transparency and accountability by publishing
accurate and detailed figures on development
cooperation policies targeting HRH and especially on
spending dedicated to HRH within health ODA.
Promote the integration of a gender approach into health
workforce policies and measures to increase
recruitment and retention of female health care workers
by addressing gender segregation, gender based
violence and other discriminatory factors within the
health system.
In line with the principles of complementarity and
coordination as stated in the Paris Declaration on Aid
Effectiveness, incentivise international NGOs and
multilateral initiatives to reduce pull factors in health
migration by requesting adherence to voluntary codes
of conduct, such as the NGO Code of Conduct for
Health Systems Strengthening.
36
72 Examples taken from Madagascar, Tanzania and Spain.

Domestic Health Policy
At home, European Member States should:
1
2
3
4
5
Develop clear time bound national action plans with
measurable goals and SMART and gender-sensitive
indicators guiding the full implementation of the WHO
Global Code of Practice on the International
Recruitment of Health Personnel and the EU
Programme for Action on the Critical Shortage of Health
Workers at the national level, clarifying the respective
roles of the various Ministries responsible and ensuring
inter-agency coordination.
Develop coherent, sustainable and gender-sensitive
national health workforce policies to enable selfsufficiency
and remove the need for international
recruitment. This includes:
a) Training sufficient numbers of health workers
according to meet the health needs of the population.
b) Ensuring a well balanced distribution of the health
workforce nationally. In the case of countries that have
decentralised health systems such as Italy, Spain and
the UK, improve and strengthen coordination and
collaboration between regions by means of a
common database and a monitoring and evaluation
framework.
c) Increasing efforts to retain existing health
workers through the improvement of working
conditions and career opportunities.
Where they are lacking, institute as a matter of priority
national health workforce information systems
that allow the monitoring of migration trends and
evidence based policy making.
Act to regulate the international recruitment of health
workers by private agencies, not currently covered by
the WHO Code of Practice.
Maintain levels of investment in the national health
systems and adequate salaries for public sector
workers, even in the face of budget deficits.
37

8
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List of Acronyms
AfGH Action for Global Health European NGO Network
AIDS Acquired Immune Deficiency Syndrome
EU European Union
GDP Gross Domestic Product
GNI Gross National Income
HIV Human Immunodeficiency Virus
HRH Human Resources for Health
HSS Health Systems Strengthening
IHP+ International Health Partnership and Related Initiatives
IMF International Monetary Fund
ILO International Labour Organisation
MDG(s) Millennium Development Goal(s)
NGO Non-governmental organisation
ODA Overseas Development Assistance
OECD Organisation of Economic Cooperation and Development
UNAIDS The Joint UN Programme on HIV/AIDS
UNDP United National Development Programme
UNFPA United Nations Population Fund
WHO World Health Organisation
38

© ALLAN GICHIGI/IRIN